Glasgow Coma Scale What is new? Dr.Venugopalan P P Director and Lead consultant in Emergency Medicine Aster DM Healthcare

What is GCS? The Glasgow Coma Scale provides a practical method for assessment of impairment of conscious level in response to defined stimuli.

“The Glasgow Coma Scale is an integral part of clinical practice and research across the World. The experience gained since it was first described in 1974 has advanced the assessment of the Scale through the development of a modern structured approach with improved accuracy, reliability, and communication in its use.” Sir Graham Teasdale Emeritus Professor of Neurosurgery University of Glasgow

When looking back... ●The Scale was described in 1974 ●Graham Teasdale and Bryan Jennett ●Way to communicate about the level of consciousness of patients with an acute brain injury. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81-4

GCS Score What was our Understanding ?

What is new ?

One

Two

Three

Where and how to stimulate ?

No Painful stimuli Only pressure stimuli

Four

Check Observe Stimulate Rate 4 systematic steps in GCS assessment

●Spontaneous ●To Sound ●To pressure ●None

Mnemonic E- Eye opening Spontaneous S- Sound P- Pressure N- None

Eye opening

●Oriented ●Confused ●Words ●Sounds ●None

Mnemonic FI V E rbal

Verbal Response

●Obey commands ●Localizing ●Normal flexion ●Abnormal flexion ●Extension ●None

Best motor response

Charts

Confounding factors rendering one or more components of the Glasgow Coma Scale untestable ○Drugs (anaesthetics, sedatives, neuromuscular blockade, etc) ○Cranial nerve injuries ○Intoxication (alcohol or drugs) ○Hearing impairment ○Intubation or tracheostomy Use NT whenever such factors are existing

Confounding factors rendering one or more components of the Glasgow Coma Scale Untestable ○Limb or spinal-cord injuries ○Dysphasia ○Pre-existing disorders (dementia or psychiatric disorders) ○Ocular trauma ○Language and culture ○Orbital swelling Use NT whenever such factors are existing

Paediatric GCS

Few areas of confusions…. GCS

Prevention and management of missing components ●Avoid missing values ❖ Temporary stop sedation (wake-up test) ●Simple imputation (same value for each patient) ❖ Record the verbal scale in patients intubated or with tracheostomy as V T (ube) ❖ We advise against assigning a score of 1 to eye and verbal components in sedated or untestable patients

Prevention and management of missing components ●Statistical imputation (single or multiple imputation) based on data ❖ Imputation of verbal score from eye and motor components ❖ Imputation based on other patient characteristics

Strategies to improve GCS ●Describe the responses of each of the components in individual patients ●Use the extended six-point motor subscale and 15-point score ●Do not assign 1 for imputation of missing values ●Chart and display changes over time

Strategies to improve GCS ●Limit the use of the score to classification and research ●Improve standardisation in assessment of patients ●Develop training instruments and implement quality improvement programmes ●Use the scale for prognosis only in combination with other prognostic factors (eg, Age, Pupil reactivity, and Imaging)

GCS -P Pupil Reaction Scale PRS

GCS P The GCS Pupils Score (GCS-P) was described by Paul Brennan, Gordon Murray and Graham Teasdale in 2018 as a strategy to combine the two key indicators of the severity of traumatic brain injury into a single simple index

How do I score GCS-P ●GCS-P is calculated by subtracting the Pupil Reactivity Score (PRS) from the Glasgow Coma Scale (GCS) total score GCS-P = GCS minus PRS GCS-P is Ranging from 15 to 1

How do I assess PRS?

Advantage of GCS P ●GCS and the pupil response to light are both related to outcome ●Combining the information together in the GCS-P extends the information provided about outcome to an extent comparable to more complex methods of combination of the data ●Improve decision making about patient care, and assist in stratification of patients into clinical trials.

Advantage of GCS P ●GCS-P Score may also be a useful platform onto which information about other key prognostic features can be added in a simple format likely to be useful in clinical practice

Evidence based exercise In the first paper, Brennan, Murray, and Teasdale describe the development of the Glasgow Coma Scale-Pupils score (GCS- P), a simple but elegant tool that extends the information collected by the GCS score on the severity of TBI.

Evidence based exercise The authors examined 1. Relationships between GCS scores and pupils’ reaction to light 2. Relationships between these factors and patient outcome 6 months after injury

Evidence based exercise They examined data from ● CRASH[1] and IMPACT[2] ● The two largest databases containing information on individual patients with TBI

GCS P Case study Imagine that you are asked to assess a patient who has been ejected from the passenger seat of a car at high velocity. They make no eye, verbal or motor movements spontaneously, or in response to your spoken requests.

GCS P Case study ●When stimulated their eyes do not open ●Make only incomprehensible sounds ●Flex arms abnormally ●Scored as E1V2M3 using the Glasgow Coma Scale ●Sum score of 6.

GCS P Case study ●Now test their pupil reactivity to light ●Neither pupil is reactive to light. ●Pupil Reactivity Score (PRS) of 2. ●GCS-P can then be determined as GCS- PRS ●In this case it 6-2 =4.

GCS P Case study ●GCS 6 there is a 29% chance of death at 6 months ●When the pupil reactivity and GCS are combined to give a GCSP, the mortality increases to 39%

GCS -P and Mortality

GCS -P ●Used as an index of ‘overall’ brain damage ●Distinguishing head injuries of differing severities ●Monitoring their progress and prognosis

GCS -P ‘Brain stem’ features were not incorporated into the scale, but were expected to be assessed separately There have nevertheless been views that more complex scores, with extra features would be useful.

Age

GCS PA ●GCS Pupils Age prognostic charts ●Developed by Gordon Murray, Paul Brennan and Graham Teasdale, and published by the Journal of Neurosurgery in 2018 ●The charts provide a simple graphical presentation of the probabilities of outcome from traumatic brain injury based on GCS, Pupil reactivity, Age and CT scan findings.

GCS Pupils Age prognostic charts ●Four prognostic factors contain much of the information about prognosis of people with an acute head injury ●GCS, pupil reactivity to light, age, and the findings on ●Computer Tomography (CT) scan are the most useful investigative index

GCS Pupils Age prognostic charts ●Combining them to convey information graphically about risks of mortality, or the prospects for independent recovery, after head injury. 1.GCS 2.Pupil reactivity 3.Age 4.CT Scan finding

GCS PA ● Observed the additive effect on outcome that occurs when age is added to the patient’s admission GCS-P ● The risk of death after TBI increases as patient age advances ● At all ages the risk of death increases as the GCS-P decreases.

GCS - PA ● Probability of favourable outcome is greater in younger patients and in patients with higher GCS-P

GCS -PA Charts ● The authors created two prediction charts based on the GCS-P and patient age stratified into 5-year increments (GCS-PA charts) ● One chart clearly shows risks of death ● Other chart probabilities of favourable outcomes in patients 6 months after TBI.

6 month mortality

6 months favorable outcome

GCS Pupil & Age

These factors have been validated in earlier studies to be the most important prognostic characteristics in head-injured patients.

GCS P A plus CT findings ●CT findings are the other important predictor of patient outcome ●CT scan findings showed the differences in outcome are very similar between patients with or without either a haematoma, or absent cisterns, or subarachnoid haemorrhage

GCS P A plus CT findings Taken in combination there is a gradation in risk with increasing numbers of any of these abnormalities A simple extension of the prognostic charts can then be made by stratifying the original charts into three CT groupings: ●No ●Only One ●Two or more CT Abnormalities

GCS-PA CT charts ● Simplify three different abnormal CT findings into scores based solely on the number of abnormalities ● Created two sets of three predictive charts based on the GCS-P plus patient age and number of CT abnormalities (GCS-PA CT charts) ● Charts for No CT abnormalities,Only one abnormalities & Two or More abnormalities

GCS-PA CT charts 1. One chart follows probabilities of death 6 months after injury 2. Other set follows probabilities of favourable outcome at the same time point. ● Charts can be used by clinicians in decision making ● Communicating predictive information to other clinicians, patients, and caregivers.

GCS PA CT Prediction Charts

GCS PA CT- prediction charts 6 months Mortality No CT findings

GCS PA CT prediction charts 6 months mortality Only One CT findings

GCS-PA CT prediction charts 6 month mortality Two or more CT findings

GCS PA CT Prediction chart 6 months Favorable outcome No CT Findings

GCS PA CT Prediction chart 6 months Favorable outcome Only One CT Findings

GCS PA CT Prediction chart 6 months Favorable outcome Two or More CT Findings

GCS-P- A - CT prognostic Tables ●Developed from data created by the IMPACT and CRASH studies ●These studies include patients exhibiting a wide spectrum of haematoma. ●The size of the haematoma or severity of subarachnoid haemorrhage does not need to be separately considered ●Size and severity will influence the GCS and pupil reactivity

Summary

Authors response on the studies “Decisions about patient care in the immediate aftermath of a head injury are influenced by physician perceptions of the patient’s likely outcome, so it’s important that assumptions that underlie these decisions are correct.

Authors response on the studies “Working together between Glasgow and Edinburgh, we have developed the GCS-P and associated prognostic charts. These simple and easy to use tools provide reliable estimates of outcomes at 6 months and will support clinician decision making in neurotrauma.”

How to assess GCS ? Video

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Resources

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